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Impact Aid Program Source Check Form Extract<br />
The survey date is December 11, 2007.<br />
Federal Property: CA003062 Address: 920 62ND ST<br />
(1) (2) (3) (4) (5) (6) (7) (8)<br />
ParentiGuardlan's ParentiGuardian's Branch of Service ParentiGuardlan ParentiGuardlan Name of Pupil Living With Pupil's Pupil's<br />
Name Address (<strong>In</strong>cluding rank, <strong>In</strong> Column (1) <strong>In</strong> Column (1) ParentiGuardian <strong>In</strong> Date of Grade<br />
If applicable) lived on worked on Column (1) Birth<br />
or above property above property<br />
Foreign Military as of as of<br />
Government survey date survey date<br />
YES I NO YES I NO<br />
CHRISTIYA TAYLOR 920 62ND ST #1 X Christopher Alsobrook 5/27/1991 10<br />
Renata Hancock 357 49th St #6 X Reniah Baker 1/25/2000 2<br />
CASSANDRA BARRANCO 3017 WEST ST #3 X Qulsan Barranco 7/27/1998 4<br />
Jeanette Blackmon 357 49th St #4 X Oareion Blackmon 4/15/2001 1<br />
Can Bolling 920 62nd St #3 X Deonle Bolling 217/1996 5<br />
TAMEISHA O'GUINN 365 49TH ST #8 X Rossaun Bowser 7/16/1999 3<br />
Daniel Broadnax/ALEXIS HALU 3017 WEST ST #2 X Porsha Broadnax 3/20/1995 6<br />
TONYA D. WILSON 365 49TH ST #5 X Keniard Bull 8/16/1991 11<br />
ALMATEEN TWEEDIE 648 57TH ST #4 X James Bums 12/2/1992 9<br />
LATOSHIA HUDSON 3017 West St #7 X Dreamius Cosby Jr 9/10/1990 11<br />
STARLET ROBINSON 365 49TH ST #6 X Jamaila Davis 6/5/1991 10<br />
Saundra Dickens 5805 Canning St #3 X Sean Dickens 5/5/1993 9<br />
ClARA LEWIS 365 49TH ST #3 X Damaglo Garrison 217/1998 4<br />
Starlet Robinson 365 49th St #6 X Dereck Gordon 1/24/1999 3<br />
This Is to certify that the <strong>In</strong>formation shown under columns (4) and (5) This Is to certify that the <strong>In</strong>formation shown under columns (4) and (5)<br />
olthe foregoing sheet(s) Is correct for the person listed under Column (1) of the foregoing sheet(s) Is correct for the person listed under Column (1)<br />
on the survey date. on the survey date.<br />
Signature Date Signature Date<br />
Title Agency Title School District<br />
This information is the basis for payment to this school district of federal funds under the Impact Aid Program (Title VIII of the Elementary and Secondary Education Act).<br />
This form must be signed and dated for this school district to receive funds based on this information.
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